HomeMy WebLinkAbout0116 GREAT BAY ROAD - Health 126 GREAT BAYi OSTERVILLE
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LOCATIO��r �f �°"I'F�11' 17A.v �� SEWAGE # � 7
vILLAGE 6)S TS�2 a ~ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
�TlZ�4e2.J
LEACHING FACILITY: (type)16 �Z4e,-", 1'r3 }. (size)
NO.OF BEDROOMS -�
BUILDER OR OWNER
PERMTTDATE:3 2 — COMPLIANCE DATE: �` ^
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching faci ' ) Feet
Furnished by G
LIa
c
3a y
t�
7dis,
No... .........-....... Fps )O...
THE COMMONWEALTH OF MASSACHUSETTS
Q` BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Divi-pw3al Wnrk,i Tomitrnr#inn ramit
Application is hereby made for a Permit to Construct ( ") or Repair ( ) an Individual Sewage Disposal
System at: ,
.....�. .- ,•. ...................................... .............................................
Locatiou \ddres or Lot No.
;-I � 6
----------------- ....�..... fi'�- -2 ------ a M j � _...s.r s� ......
Owner ------•-------------------•-•------•---•-•--Address
Installer Address ��``__
UType of Building S Size Lot____......3j_.&]...Sq. feet
0-4 Dwelling— No. of Bedrooms__________ ------------- ion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons...........-................ Showers ( ) — Cafeteria ( )
f-4 Other fixtures ------------------------------ -
W Design Flow___________________________55........gallons per person per day. Total daily flow-____......_._.._...__.....5.5.fi-'._..__gallons.
Gd Septic Tank—Liquid capacitvX_�PQ_gallons Length_______________ Width-------P._______ Diameter......__-______ Depth................
W � e
x Disposal Trench—No. -----�............. Width......1�-------- Total Length.____36........ Total leaching area-------- .sq.. ft.
Seepage Pit No---------------_----- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank ( )
~' Percolation Test Results Performed by.___.._.� x ._...A.._...�`��..._��L...... Date.........................
Percolation
,tea Test Pit No. 1........2'.minutes per inch Depth of Test Pit--------1__0...... Depth to ground water......._..-.`..___..
(Z4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a -.................. •...................•---•--•---•-•--•-•-•-•------••--••----...................._......------•-•--••............................
Descriptionof Soil Q 1 -------------------------------------------------------------------------------------------------------------------------
xl `2-•-•--5,�1�SC1�= -----------------------------------------------------------V ---------------------------------
Aen
W ---------------------------------------------zc"_,f'_.._.. ..._. N
U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------_...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to lace the
system in operation until a Certificate of Complia ce has been ' ed health.
2 /
Sign -- . . ....b........ .. . ......
-
ApplicationApproved By ..... ....... . .... .............. L'1. ... .. -. ..-----'—..... .. .. .. ............--- .. .... ....Dace ...�...
Application Disapproved for the following reafonr
----------------------------------------- . ...... .. ---------------------- ----------------------------------------------------------------- - -.........................
Permit No. ... . .. f ... - Issued ........( ... '{/A D--e------
— �� )
_....... FEz. ./..�!.....
No.
7�3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
AVVIkation for DbriVoiial Worbi C omitrnrttnn ramit
Application is hereby made for a Permit to Construct ( " ) or Repair ( ) an Individual Sewage Disposal
System at
.....I. -.'. ..........................................
........ .............................................
,atio
................ _0.►' N%: n �re5 �N , Jq"- f '31� AA 1N Sod of No.1�(�0�1 e ssr4. : .
Owner Address
/ca
Installer Address
U Type of Building Size Lot____ ...Sq. feet
Dwelling—No. of Bedrooms--------- ---------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------------------•-•----•---•----••••---••--•-••----•-•.........----
W Design Flow.............................. 11�-_____--gallons per person per day. Total daily flow---------------------------'5.S-S2_-_--gallons.
WSeptic Tank—Liquid capacity._;Qg_gallons Length---------------- Width---------_------ Diameter---------------- Depth................
x Disposal Trench—No. .....1.............. Width......1,�-------- Total Length...... .__..._. Total leaching area_._.....�-�-�_sq. ft.
Seepage Pit No---------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( _� Dosing tank ( )
�-' (-3AX-r6z...... ---0-1
......._. 11�- S
Test Pit No. 1_._.__�'_minutes per inch Depth of Test Pit_.._.._.I.b____.. Depth t� ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 ------- ---------- -----------------------------------------
•----------------------------
.....
...
----------------
---------------------
...--------••---
O Description of Soil.............. ( ------- --------------------•------------------- ---
U --------------- t SvSOIC�-`
-----------------------------------------------------------------------------••--•---•---•-----•---••.
UW --•-•------------------------------------------ .=--�0--- IM Win.....S. N -------------
Nature of Repairs or Alterations—Answer when applicable............._--._._----_-_--..................................................................
.. ........_
Agreement:
— The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation,until a Certificate of Compliance has been issued b t =oard health.
Signed .--- —- ,3. y- ........ 6�
.� ;,vim✓ i„7 -/- - - --...... -- �
Application Approved By .._...._....... -�..� ---....�.. / r �' ----=!,t�. ------------ %. .... (i l ./
T _..�..,_. .�r- .....
`-Dace
Application Disapproved for the following rearonr
...................................................r------�------- .._........o-:------.---------------------------------------------...----..-----------------------------�W
...-P------------------------
---- Date
( !' l — j I
Permit No. LL .......... ,/ � <-7--------- Issued ..... . ..
Dare
THE COMMONWEALTH OF MASSACHUSETTS
1
BOARD OF HEALTH ?
TOWN OF BARNSTABLE
Tertifirate of (garayliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ................................. ................................ ....-------------..---------------------------------------------------------------
h,�:aie
at -------------_---_ ----I-------............��(}C '1-....__-�L�- . ....._....PAD-----------.....U.ST'�---t/---L��---------------------------------------
has been installed in accordance with the provisions-of TITLE,5�of The Sraxe Environmental Code as described in
the application for Disposal Works Construction Permit No. __ ---A07"`...._.._f� '�� dated ....._...._----------------------------- -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UEA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .--- - -- ------------- InspectoF
------------------------ ----------------------------------------L------
THE COMMONWEALTH OF MASSACHUSETTS
rt BOARD OF HEALTH
TOWN OF BARNSTABLE
No..................j.... FEE...,.....__........---..
�tiipoal urk.ii Tomitrution "rrntit
Permission is ereb raantted�•-------•-�- ------------------------------------------------------i----------------------------------------------------.-.----------
Yg
to Construct ( )� or Repay ( ) an Individual Sew a e Disposal System
I..J .. ......... .
at No......--............................................................f t4 =-0 n---...------a-5 tJ
Street ...-
as shown on the application for Disposal Works Construction No.- �___._ ____ D ed...........................................
c] f � Board of Health
DATE. .......................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
sl W DATA -
��6L FAMILY 13ED20w SKEET 1 op ,L —
•- GAeBAGE G(LJJJDEQ.
�AIL�( �LOK/ Sx1Io =55t •�P►� SEE PLAtN C4 P>aGI(„ I�E(zC:O
SEf3T1 C TA 0 L 55a X(C-0 70-.> Zs �
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Torte DESIGN' -10&VD �T�IL OF DIS AL F-IF_/ 7--,
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1x, SET"�huc I? ulZr=/fit: S of THE TWO OF'P%2t 5TA&t nn
AN>>. 15 ��ATEb \A/Iru lu 'A 'FLaob 447AWr> Zo+JE, 1( �� . 49
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No. --- Fee---------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*r Well Cootruction Permit
Application is/hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at:
-------------------------------------------------------------
Location Address Assessors Map and Parcel
--------------�----------------------- ------- --------- - - - ------------------
Owner /) �+ Address
&A---'��^av_Q` ---------------------------- - - �°�
--- - - - ----------------------------------------
Installer — Driller Address
Type of Building
Dwelling--------------------------------------------------------
Other - Type of Building----------------------------- No. of Persons------------------------__—_—_______
r �
Type of Well y------;---- - ------- Capacity---------------------—--- - -——
Purpose of Well-1 2 (PcA t'p"j--_e�1 -------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Ce tifica a .of Compliance has been issued by the Board of Health.
Signed
4/h
-------- ---- — — date
Application Approved By — --- -.A- �---
date _
Application Disapproved for the following reasons. -------------------------------------_—_______
— —-- ---- — -- — — -------------------
date-----
Permit No. ------- Issued----- -- - - - ---— - -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliante
THIS IS TO CERTIFY, That the Individual Well Constructed (-I, Altered ( ), or Repaired ( )
by------- -- 6 A --------------------------- --------------
installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. --------------_____Dated------THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE—--- -- - -- Inspector------ —- -----------
' No.-- ------- -------- . _ - Fee---------------------
BOARD.OF .HEALTH. '
TOWN .`OF :BARN STABLE.
p ZIP
Cicationore[C Contruttionerttit
Application is hereby'made'for a permit to Construct (�.Alter ( ), or Repair ( ')an individual Well at
0 66 T" oar ,
Location""—'"'Address'r, — ` Assessors Map and Parcel,.
-- -R? — — -----
OwnerAddress i 1
S
ri
--�- A- -- - - -=-- - - --
Installer — Driller Address
-
Type of BuildingT..
Dwelling-==
Other -.TYPe of Building -- -- No. of Persons---=- - ---- -
_
i '
1
Type of Well- - - Capacity==
rp y — -• ��_ -- -- - -- =
Pu oseof Well-Ld/_6c ��-ti'- stilt _
E Agreement: `t _
The undersigned agrees to install the-'aforedescribed individual well in accordance with`the provisions of The
Town of Barnstable Board of Health Private.Well.Protection Regulation = The undersigned further agrees not to
place the well in operation until a Certificate .of..Compliance has been issued by the Board of.Health.
--
. date' e ,
r
r Application,Approved By y aare - -
Application Disapproved.for,the following reasons:_ --- -- ---- - -----
/ to da —
Permit No.- ! -- _ Issued --= -- date,
-.�@i@iew@�}ta@fW_�i'v{c4i.!�•:sY;SliP�Si!��1,ia'�t'iaf4ieo!:iNTY'si68maa_6wL'loe_"2Fdi<sii$ee`WTiV1S•J�'696'D'ehR�9d?YliKP"cEe�.9'AeK4Geit,Ti'XoTiili!! 9i4SAJG�2S4!a�6`1I.4:6lfiPi!!WI�QYCY!4�-E6'�,d
BOARD.-0F HEALTH
TOWN.-OF, BARNSTABLE^
ertif irate f ta
THIS IS TO CERTIFY, That the Individual Well Constructed (`'f Altered ( )',:Or Repaired
by -.: _ S cc, +�-� ( -=- -- --- ------ - ---- -- -- ---
— — Installer
has been installed.in accordance with the provisions of the Town of Barnstable Board of Health Pnvate Well Protection '
Regulation as described in the application for Well Construction Permit,No,- -`---:-------- `Dated . ------- -------- r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT-THE WELL,
SYSTEM WILL FUNCTION SATISFACTORY.' .,."
DATE---- -- _ Inspector - -- --- -
Nowi6�s14:i41N'i9itL@Yeieieii^l4Ji�i9Nb'k"�'M�1GQiA�l144i i r3se:a�Cmi,ayiwe arpea�jpwfis�da.'�: ir-�'sec4�eK@A!i�am a�iia�fii s+!e4m! :ie;u�t s,*t�-.r'!A 1a='=1.a� @4`ii.�06+fe,�.s _:.assE
BOARD OF HEALTH' '
TOWN OF BAR'NSTAB,LE
eCCoritruc con hermit
--- r
No. -- Fee-
Permission is hereby granted p S G4;iv► ' �� _ — _ —__
to Construct Alter ( .) or Repair (. ) an.Individual Well at:
-- ----=------- - --- --- -----
Street
as shown.(on he a lication fora Well Construction Permit
No.- 1. ---- ----
a Board of Ie 'r
DATE .
ENI?ROTECH LABORATORIES, INC.
MA CERT. NO.: M-MA 063
449 Rte. 130
Sandwich, MA OZ563
508 (888-6460) 1-800-339-6460
FAX(508) 888-6446
CLIENT: Sumner Tilton LOCATION: 126 Great Bay Rd.
ADDRESS: 370 Main St. Osterville MA
Worcester MA 01608
COLLECTED BY: D. Pennini/DA Scannell SAMPLE DATE: 4-22-98
SAMPLE TIME: 1:00
WATER SAMPLE TYPE: New Well DATE RECEIVED:4-23-98
LAB I.D. #: 984504
i
WELL SPECS.: 20'
RESULTS OF ANALYSIS:
Parameters Units Recommended Results Method Date Analyzed
Limits
Coliform bacteria /100ml 0 0 9222 B 4/23/98
pH pH units 6.5-8.5 5.84 4500 H+ 4/23/98
Conductance umhos/cm 500 88 120.1 4/23/98
Nitrate-N/Nitrite-N mg/L 10.0., _ 0.02 4500-NO3 E 4/23/98
Sodium mg/L 28.0 `, 00.0, 200.7 4/23198
Iron mg/L 0.3 ,z-_ 0.54 - ,_ � ' - _- 200.7 i -° 4/23/98
Manganese mg/L 0 05=M '0.790" ` o- 200.7 :_;� 'a 4/23/98
COMMENTS: Low pH indicates high corrosive characteristics.
Iron and Manganese are not a health hazard, but can cause taste,
staining and odor problems.
YES WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED.
o`��.:ky:�3i1i?�: _.;. F3 t1• ,�'q?` =Pt"t � •.Y !.t 7 S� ,.9
;Ro ald J. Saar
Laboratory Dir ctor- -
<=less than
>=greater than
TNTC=too numerous to count
ASSESSORS MAP NO' ELL
d �,�i PARCEL NO.
No.- - ------------- Fee------------ -
BOARD OF HEALTH
TOWN OF BARNBTABLE
A.ppticationArVe[[ Con!5truct ion Permit
Applic on is hereby made for a p rmit to Construct ( VI, Alter ( ), or Repair ( )an individual Well at:
�J _�� bid os c���l�, - �''.cG=- --
- ------------------------- ------------------------------------------------------------------------
Location — Address Assessors Map and Parcel
- ' = ' 6`-"---------------------------------------— --- a 6 `' `- -d S�`c c� lG�
------------
[� .[pf (� // Owner P /� Address/
— 1--R--- :v v�'r!1---------------- —----------------------- '=6 -/J O�( 6 G S�1 - — -----
Installer — Driller Address
Type of Building
Dwelling--------------------------------------------------------------
Other - Type of Building ---- ------- ----------- No. of Persons------------------------------------------------------
Type of Well ----------------- -- --------------------
Purpose of Well--i t/ i��1t e'---------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until daC rtificate .of Compliance has been issued by the Board of Health.
Signed --
pdate
9-1
Application Approved B -- - — ��� - - - -— �` fs
date
Application Disapproved for the following reasons:-------------------------------------------------------------------------------_-___-______-_
- —-- -----------_-----— --------------------------------------------------------------------------------------------------
date
Permit No. -- --E= � -- Issued---�/- � �'—---- ------- ---------------------
date
BOARD OF HEALTH
TOWN OF BARNBTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (') Altered ( ), or Repaired ( )
by-- -- - - `"'+`'�
------------ -----------------------------------------------------------------------
------- ----------- ----------- ---- ---- -- -------------
Installer
�6 6 o /RBI
at- - — -- ----- — aS� ------0
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permi o---tiffk/t.Dated - -k� �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- - --—- Inspector----------------------------------------------------- -----------
t� C .. 1.-, »r,t„'. f «,.,s-�.", •t ...+.�ss..a..>,.s r... ".M.ti >
1
----��1--.----
No.- --------------- Fee
r B OF HEALTH
TOWN OF BANBTABLE
ApplicationJforVell CongtrurtionvYernut
1 i
Applica n is hereby m ce�f r p rmit to Construct.('�, ,,Meer ( ),/or Repair ( )an'indi dual Well at:
kpplicV
— — — —
7 . Location Address _' Assessors Map,and Parcel
Owner Add Tess
L
-----------
Installer - Driller 4 ��f Address
Type of Building /
Dwelling -
Other - Type of Building--------------------------------- No. of Persons------- -- = -
Z;
------
Type of Well�±* _ J C ---- ---- -
CS city
-�-
----- -------- -------
� /�4_ r
Purpose of Well-- ----1---- I�-_t-�°"---------------------------------- 7j
,. ;
,�
Agreement: '
The undersigned agrees to install the aforedescribed individual well in accordance �/ith the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation -/The undersigned further agrees not to .
place the well in operation until a C rtificate.of-omplra e-l�as_b-een-i ss�ued by the Bo rd of Health.
Signed - -- - - - ------ -
--- ---- -------------------
fd�attee
!: Application Approved B = ��' !`-� -----— - �'-��
/ date
Application Disapproved for the following reasons:-------------------------------------------------------- ---------------------
---------------------------------------------------
/ / date
A __< Issued---- -- -- - ----------
Permit No. -------- —__— - - - - -
date
._. � ...ic.a.�.xs..,..rya.�arw.:a:+c-,.--..-.,:-a:ct.�.:.:,t..�:sq..i4+■..�e'r�:re�r..f:wwe�.4.sr.au.ae,>��hr�4..W M.w aei�..,w.w
i
BOARD OF HEALTH
!TOWN OF BARNSTABLE w
Certifirate Of ComplWire
THIS IS TO CERTIFY, That the Individ al Well Constructed (' Altered ( ), or Repaired ( )
Installer
/ �aS�`t l f[_' ---- - - -------------------
has been installed in accordance with the provisions of the Town of Barnstable
Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permif>PVd' — ---Dated - -X/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- --- ------ — - - ----- Inspector--------------------------------------------------------------------------
._ .. - -.w- s..r�..a..o�.su.r..�r.r,.M...M..,..r.....N.r..�i,.eMw.w�W.nc» .. ... .0.4U4iP .rfr».,:wr-�- -,.
BOARD OF HEALTH
TOWN OF BARNSTABLE
Well Congtruct ion Permit
No. -4�- ==—or
` Fee -----------
No.
,o A S�U.�,�
Permissionis hereby granted--------------- -------------------------------------------------------------------------------------------------------
to Construct (V), Alter ( ), or Repair ( ) an Individual V�11 at:
No. --------------- -- -JJ4U t /t�cl Z>Sty v t 1 r
e �— — Street
as sho on the�pglication for a Well Construction Permit
No. - - ---- ---- ?--- --- -- — - - Dated-- - - - ------ ----------------------------
n, '�._
Board of Health
DATE- ----/-----1-- --
. �
N�
�`� S�
��
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� ��
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I
APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION_ - 125 Ge-C—A_- "6'R-< ZDAD CLur I L i rT z t,5_4.Nx - NO.
VILLAGE 0",7 zz l L-LG DATE
APPLICANT S'�r-�i to G 2 Ti L-�Ia J� FEE
1,ADDRESS ' TELEPHONE NO. (Non-refttndablc
ENGINEER plxT'�2 ��fC ��L TELEPHONE NO.-�}2�-�1�j�
DATE. SCHEDULED
(Applicant's signature)
ASSESSOR'S bi1�P�6i �,OT NUi l°l00 0 0 0 0 0 0 0 0 . . . . . . . . . . . . . :i. . . . . . . . . .
SOIL LOG f
SUB-DIVISION NAME AD TE 3/ 7 TIME 101�30
EXPANSION AREA:. 'YE'$.�NO�_ �.-�-�
TOWN WATER
PRIVATE
BOARD OF HEAL':
�OQC/_- MA,7eALt-j STD(2EXCAVATOR
SKETCH: (Street name,etc. Idimensions of lot, exact location of test holes and
• percolation tests, locate wetlands in proximity to test holes)
_ `^ NOTES:
`vT?
S.I-20:a.
,602
57639'08•E �^
\1 19&OS' 20.0 •
�' NN •
3� 6
• �I I _/ N9 tit
iM0
So -LIOT
. QI 1:�b... ... � DRIVE�.__� J0'' ��9 � // 61�•f,m .
-
g1.all. 1IB6
1.00 OU
17olSJ
•� I a y0 /; /00 0
� + � y3j•66N� I. s �,� S60h�1��
4,
\� �;R0O• -
. 'f9�j t' \ e•INO.1 t i���
t
, :. PERCOLATION RATE Leqi, i-v4^&4 2Mtkj', kpareIy�•t{
TEST HOLE NO: I ELEVATION: TE5T HOLE NO: CD ( ELEVATION:
1 F! Lo s.-A,\
t,E,vawi 1
�76 soSL, 2
3
3
4 Ep CLC--A 4
6 Z Palms
8
8
9 1�
, ••10 9 �64�.�a��t t� : . .
tp 10
• 11 11
12 12
13 13
14 14
15 15
16
SUITABLE FOR SUB-SURFACE SEWAGE: • LEACHINGIFIELD) , LEACHING PITS
LEACHING TREN.CHEST _k_
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: MAC
NOTE: ENGINEERING PLANS MUST SHOW NUMBER-ASSIGNED-ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIR . BX P E At1j� RFi't RNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION_ �D ( LU-T 2� �► T�-C= ,SSA ru p NO.
VILLAGE_- � -T L-L E
' DATE
APPLICANT �IJM E Tz �i r_rtb�y FEE
LADDRESS TELEPHONE NO. (Non-reftndablc
� .
ENGINEER qc-:7 l K,L TELEPHONE N0. _a- 2 +
DATE. SCHEDULED
(Applicant's signature)
11SSBSSOR'S�b11�F3�6i.I.OT IVCUi . o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o�. . . . . . . . . . . . . . . . . a . . . .
'7zlto
SOIL LOG
SUB-DIVISION -NAME wi'1
DATE_ 3171 TIME
EXPANSION AREA: YES -NO (�q � �y� iL ENGINEER:'?�' '
TOWN WATER�PRIVATE WELL
BOARD OF HEAL?
' '• - M�Gq L(-t57 ,e— EXCAVATOR
SKETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and
Percolation tests, locate wetlands in proximity to test holes)
NOTES:
tYz
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n�
�•lS.OY.ttS g3.[$0
1
41
2� n•'•'/•o � Y '� .
p 1N YZ•0 •� \ Iy'
•t6'OE( •6S1 z n •SOY !,o°N MISOY
9: IIS r \ r•
N �•i
0 0� \• m � v
3] o
N '4 uu b / H
N N �• �• C O
rN•' O N O` m •Y w✓
hm •� 0 II m \ 6
Y V
1 0
° \ °I\� \ 0.137•
8 S
= va 08 3Nn[ cis 9'S[t 3? p2 C Ou ¢ b1 n
.. � 0�.09.5[I
PERCOLATION RATE: Z- M A) ?ar?-
TEST HOLE NO: I ELEVATION: TEST HOLE NO:
1 ELEVATION:
' 2 (=1 c.Q 1 Ft LLr
f C_ 2
• 4 �vUd 1�1 3 Lo A �7U i3�tL
T 4 _
6 Cc.G,Ak� 5 C LC—ram
� . 6
8 �A�O 7
8
9. 9
:i(� 10
11 t0
12 �1{��'. 11 �.�A
12
13 13
14 14
1S 15
16
SUITABLE FOR SUB-SURFACE SEWAGE: 16
• LEACHING FIELD C LEACHING PITS
LEACHING TREN:CHE§j&_
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER- ASSIGNED .ON PERC' TEST APPLICATION
ORIGINAL: . COMPLETED N ENT R p
' COPY: RETAINED BY APPLICANT TURNED TO BOARD OF HEALTH
TOWN OF BARNSTABLE A I(✓ Vfitv(s
G
1 ,l® T_ t A/ -L 0 N ISUNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS / � 1:�
ASSESSORS MAP NO.,. PARCEL NO.
ADDRESS! /.2 .. .__ . VILLAGE-.:
O�-
14AME;
A a,
CONTACT PERSON PHONE NUMBER
LOCATION OF, TANKS;. CAPACITY:__ -- _.TYPE-OE_FUE AGF: T.YPL: -- LEAK
- - -- r :.-
OR CeH�EMICAL*, SSUyn(- ap DETECTION
14 SYSTEM!
DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. C'rJ
!J 0 p
CENTRAL OIL CO.OF WORCESTER
t
P.O. BOX 843
WORCESTER,MASS.01613-0843
t
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